Full Version 4. Access Your Medical Records
Table of Contents
Page
What is a medical record? ............................................................................................................. 2
What is meant by personal health information (PHI)? ................................................................... 2
Why would you want to access your medical records? .................................................................. 2
What are your rights related to accessing your medical records? ................................................... 2
What steps do you follow if you want to see your personal health information? ........................... 3
Who are trustees? .......................................................................................................................... 3
Can you see all your personal health information? ......................................................................... 3
Will you have to pay for your personal health information? ........................................................ 3
How long do you have to wait? ...................................................................................................... 3
How do you read your medical records? ........................................................................................ 4
What steps do you follow if you disagree with the recorded information? .................................. 4
What is a Statement of Disagreement? .......................................................................................... 4
Can someone else do these things on your behalf?......................................................................... 4
When can trustees share your personal health information with others? ...................................... 5
What information can be shared with family, friends and others? ................................................. 5
What information is shared with healthcare providers? ................................................................. 5
Can your information be given to a religious group or fundraising group? .................................. 5
What steps do you follow if you have a complaint about a trustee?............................................... 6
Whom do you call if you have more questions? ........................................................................... 6
Resources ...................................................................................................................................... 6
You and your family are encouraged to ask for any information you need to be an active and informed
patient while receiving healthcare services. Accurate information and good communication are
important to your healthcare process and your safety as a patient.
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Full Version 4. Access Your Medical Records
What is a medical record?
A medical record is created each time you visit a healthcare provider to talk about a health
concern or receive health services. Providers record the services and care that you receive in this
record. They use your medical record to review your healthcare history. These files are the
property of the healthcare facilities.
In Manitoba, The Personal Health Information Act (PHIA) allows you to access your personal
health information (PHI), with some limits. PHIA requires healthcare providers and facilities
(called trustees) to keep your medical records private and safe.
What is meant by personal health information (PHI)?
Personal health information includes:
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Your name, address, Personal Health Identification Number (PHIN)
Facts about your health
Facts about your healthcare history (e.g. treatments, surgeries) and your family history
Facts about the care you are receiving
Facts about payments made for your healthcare
Why would you want to access your medical records?
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To learn about your healthcare history and treatments recommended or received
To give health information to another provider
To bring with you if traveling out of Manitoba for a second opinion or additional care
To gain information for life or health insurance purposes
To file a complaint against a healthcare provider
What are your rights related to accessing your medical records?
PHIA gives you the right:
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To see and get copies of your information, with some limits, within time frames stated in
PHIA
To name another person, family member or patient advocate, to access information for
you
To ask for a correction or addition, if something is incorrect or incomplete
To not share your information with family, friends, healthcare providers, religious groups
and/or charitable fundraising groups
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PHIA law applies to all recorded personal health information (e.g. paper files and computer
notes).
What steps do you follow if you want to see your personal health information?
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Ask the trustee holding your health information to provide access.
You may have to put your request in writing, using a form.
Under law, trustees must make every reasonable effort to help you. They must reply to
your request openly, accurately, completely and within the time stated in PHIA.
Who are your trustees?
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Healthcare providers: doctors, nurses, dentists, pharmacists, physiotherapists and others
Facilities: hospitals, medical clinics, community health centres and personal care homes
Health service agencies that provide health services in the home
Provincial government departments/agencies, municipalities, regional health authorities
(RHAs) or a school division, college or university
Can you see all of your personal health information?
It depends. The trustee needs to give you as much of the information that you asked for as
possible. PHIA lists situations when information is not shared. But, if the trustee does not give
you all the information you want, they must:
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Tell you in writing
Give reasons why the information cannot be provided
State you have the right to complain to the Manitoba Government Ombudsman
See Section 11 (1) from PHI Act- http://web2.gov.mb.ca/laws/statutes/ccsm/p033-5e.php
Will you have to pay for your personal health information?
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Trustees may charge a small fee for letting you see or print copies of your personal health
information.
If you are unable to pay this fee, talk about this with the trustee.
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How long do you have to wait?
By law, trustees must reply to your request quickly, based on the situation, but no later than:
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24 hours, after you ask, if you are a patient admitted to hospital and want to see
information about the care you are currently receiving
72 hours, after you ask, if you are not a patient admitted to a hospital, and want to see or
get a copy of information about the care you are currently receiving
30 days, after you ask, in any other cases
The doctor or nurse may send your request to the Privacy and Access Officer in the facility.
Some trustees may need your request in writing.
How do you read your medical records?
Medical records are created by doctors and other medical staff. At times, the records are hard to
read and you may want help. Ask if a staff person can review your medical record with you.
There may be a small charge for this service. A family member or patient advocate may be able
to help you read this information.
What steps do you follow if you disagree with the recorded information?
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If you believe information is incorrect or incomplete, you can ask the trustee to correct it.
If the trustee decides not to correct your information, you must be told why in writing.
You have the right to file a Statement of Disagreement with the information the trustee is
holding.
You can make a complaint to the Manitoba Ombudsman.
What is a Statement of Disagreement?
It is a form used to state why you do not agree with the information a trustee has in your medical
records and refuses to correct. Your Statement of Disagreement should list what information
you disagree with and what information you believe is correct. Be sure to keep a copy of this
information. The trustee must add your Statement of Disagreement to your medical record.
Can someone else do these things on your behalf?
Yes. Under PHIA, if you, the patient, are competent and want someone else to access your
personal health information, you will have to give written consent. The written consent must
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state who will act on your behalf and what you allow that person to do. For example, you can
limit what that person does in terms of seeing or getting a copy of certain information from your
medical record. If you cannot give written consent, there are exceptions under PHIA section
60(2).
PHIA states who can legally exercise your rights on your behalf. This includes a family
member, close friend, a named advocate, a lawyer or a representative.
When can trustees share your personal health information with others?
PHIA permits trustees to share your personal health information, without your consent, in certain
situations. Your consent is not needed:
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To give you healthcare services
To collect payment for your healthcare (may include private health insurance companies)
For health system planning and research
To report information, if required by law (e.g. reporting an infectious disease under The
Public Health Act)
What information can be shared with family, friends and others?
If you are a patient or resident in a hospital or personal care home, the trustee can share the
following information:
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Confirm you are a patient in the facility
State your current general health status as critical, stable or satisfactory
Give your room location
Note: Tell your trustee, if you do not want the above information shared with specific people.
What information is shared with healthcare providers?
Personal health information is shared with doctors, nurses and other members of your healthcare
team (current, past and future). Tell the trustee if you do not want certain information shared
with specific people on your team.
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Can your information be given to a religious organization or fundraising group?
Information is sometimes shared with religious organizations or fundraising groups.
If you do not want to be contacted, tell your trustee you do not want your information shared
with these groups.
What steps do you follow if you have a complaint about a trustee?
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Speak with the trustee first.
If you are not satisfied, you can complain to the Manitoba Ombudsman. This
independent office looks into complaints about access decisions and privacy of
information.
You can complain if the trustee:
• Did not reply to your access request in the time stated by PHIA
• Will not let you see or get a copy of your personal health information
• Will not let you make a correction to your information
• Did not properly collect, use, share or protect your information
For more information:
Call 982-9130 in Winnipeg or toll-free 1-800-665-0531 or
Go to www.ombudsman.mb.ca or
Send your letter to:
Manitoba Ombudsman
750-500 Portage Avenue
Winnipeg, MB R3C 3X1
Whom do you call if you have more questions?
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Speak with your trustee if you have questions about:
• Access and privacy practices or the fees of a specific health facility
• A healthcare provider or other trustee who holds your personal health information
For more information about rights to access personal health information, or privacy rights
under PHIA, you can also speak to a PHIA contact at Manitoba Health:
• Go to http://www.gov.mb.ca/health/phia/index.html
• Call Manitoba Health at 204-788-6612 in Winnipeg or toll-free at 1-800-392-1207.
(Collect calls from rural and Northern residents are also accepted.)
• Printed copies are available from: Statutory Publications, 200 Vaughan St.,
Winnipeg, MB R3C 1T5, Phone: 204-945-3101.
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Resources
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Manitoba Institute for Patient Safety (MIPS) websites: www.safetoask.ca and
www.mbips.ca.
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In Manitoba, privacy and access to health records are guided by two pieces of legislation:
o Freedom of Information and Protection of Privacy Act (FIPPA).
http://www.gov.mb.ca/chc/fippa/public_portal_home.html
o The Personal Health Information Act (PHIA).
http://www.gov.mb.ca./health/phia/faq.html
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Info Health Guide to Health Services in Manitoba: What are your Rights as a Patient?
Manitoba; 2009. www.gov.mb.ca/health/guide/7.html
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Navigating Canada’s Health Care: A User Guide to Getting the Care You Need.
Michael Decter and Francesca Grosso. Penguin Canada; 2008.
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Finding Your Voice: Our Journey with Cancer through the Health Care System. Dawn
M. White. Winnipeg, MB: Friesens; 2009. www.dawnmwhite.ca
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